CAI’s LARC Modeling Tool

1. Estimate the number of clients in the age range you have chosen that you believe will want during a future 12-month period. This is just an estimate and does not need to be perfect. You may consider using utilization data from the previous year and/or future targets to identify this value.
2. Estimate – again, this is just a guess – how these clients will be distributed across your third-party payers, as well as among your uninsured population. This will be your payer mix for your population of focus. Input these proportions (%) into the “Proportion of Clients” column. The amounts should add-up to 100%. The “Spot Check” row will help with this. In determining your payer mix, you may consider using your agency or program’s current payer mix values for your population of focus and/or any future payer mix projections or targets.
3. The provision of LARC services typically includes the following: education/counseling, examination, and insertion, as well as the device itself. The number and combination of activities that can be billed for depends on the insurance plan and your agency’s contract with that plan. Whether not your agency currently provides LARC services on-site, your institution likely already has set reimbursement rates with insurers for the insertion, removal, and cost of LARC devices. Understanding costs and reimbursements is key to calculating the fiscal impact of providing LARC on-site. Complete the reimbursement information for Columns 1-4. Your finance department will have this information if you do not. Note: Not all healthcare services providers charge the maximum allowable amount for LARC services and devices. Include the maximum reimbursement rates in Columns 1-4.
   • Medicaid Managed Care: If your State’s Medicaid Plan contracts with managed care organizations, your agency negotiates reimbursement rates for each service and procedure that is delivered to a Medicaid enrollee. Include these rates in the rows in the “Medicaid Managed Care” section. If your State does not contract with managed care organizations, then you will leave this section blank and only complete the “Medicaid Fee-for-Service” section.
   • Medicaid Managed Care – Device Reimbursement: Your State may or may not “carve out” pharmacy benefits from its contracts with managed care organizations. In States with a drug carve out, the reimbursement rate a healthcare providers may bill for LARC devices is the same as that for Medicaid fee-for-service clients (i.e., a standard rate). If your State has a drug carve out, include that standard reimbursement rate in Column 2 for the “Medicaid Managed Care” rows. In those States without a drug carve out, what a healthcare providers may bill for LARC devices also is negotiated on a plan-by-plan basis with Medicaid managed care organizations. You should be charging this amount (as opposed to the cost at which you acquire the device).
   • Medicaid Managed Care – Visit Reimbursement: It is a best practice to provide same-day access to LARC using the Quick Start method of initiation, provided reasonable assurance exists the women is not pregnant.[1] For these “Quick Start” visits, it may or may not be appropriate to bill for both an Evaluation and Management (E/M) visit and the insertion of the LARC device. If a client discusses a number of contraceptive options with a healthcare provider, decides on a LARC method, and then the device is inserted during the visit, an E/M service may be billed. On the other hand, a client may present knowing she wants a LARC device or having been scheduled to have a LARC device inserted, in which case E/M services are minimal and cannot be billed. There is no standard visit procedure code and corresponding reimbursement for LARC services. For this column, we recommend you identify your “typical” LARC visit and use the procedure code that is/can be attached to that to determine potential visit reimbursement. Remember: These values do not need to be perfect. The tool is a jumping-off point for better understanding the net fiscal impact of providing LARC services.
   • Medicaid Fee-for-Service: Make sure to include in the “Medicaid Fee-for-Service” row clients with coverage for LARC services through Medicaid family planning expansion programs.
   • Private Insurance: What a healthcare service provider may bill for LARC services is negotiated on a plan-by-plan basis. Include in the “Private Insurance” section the maximum allowable amount that each private insurance plan with which you contract will reimburse for LARC services and devices.
   • Self-Pay: Your agency may have grant funds (e.g. Title X) and utilize a sliding fee scale for those clients without insurance or who do not wish to utilize their insurance. The sliding fee scale may result in some clients paying a reduced, subsidized fee for LARC services. The row with your “Self-pay” clients should be based on the average amount collected from sliding fee scale clients (i.e. subsidized and full-pay clients). All clients who slide to 0% should be included in the “No Pay” row. No Pay: Include in the “No Pay” row all clients who do not pay anything for their LARC services, either because they slide to 0% on a sliding fee scale or because they receive uncompensated care.
   • Other: We have included an additional row in case your agency has another funding stream, such as safety net funds to cover services for uninsured populations. Include clients “covered” by this payment source in this row.
4. The column “Reimbursement Calculations” will calculate the net cost/reimbursement for each plan, and the average cost/reimbursement for the “typical” client. This amount is equal to all reimbursements minus the cost of the LARC device.
5. Scroll to the bottom to see your results and submit data.

[1] Dean G, Schwarz EB. Intrauterine Contraceptives (IUCs). In: Hatcher Trussell J, Nelson AL, Cates W Jr, et al, eds. Contraceptive Technology. 20th revised edition. New York, NY: Ardent Media, 2011, pp 147-191.